Identification Referral and Treatment of Children with Disability

Session One
Introduction Why do we need Early Identification Impairment versus Disability

The Scope of the Problem

Collecting statistics on rates of disability is difficult because there is lack of consensus as to what disabilities are included. In Guyana no statistics available but:
Nearly one person in five in USA in all ages Somewhere between 3 and 6 % of children under 5 are estimated to have an impairment, depending on region and economic status. (The % increases with poverty)

In Guyana perhaps 1 in 20 children who come to clinic have some kind of disability and many more a mild impairment that need not result in disability e.g. partial deafness that could be treated with proper use of hearing aids. We are not finding them

Why The Need to Identify Early

Many of the impairments that children have can be addressed by a variety of therapies and aids to reduce the impact on the childs life. Less than half of children with problems are identified before starting school. Without identification the child has no chance of getting the help that is needed. When the child does not get help there is more likelihood that he /she will not be allowed to enter school or is not able to do cope with school activities. EARLY IDENTIFICATION IS CRUCIAL

Importance of Timing
The developing brain is ready at certain ages to learn and organise particular developmental tasks. The window of opportunity is very specific. Some tasks can never happen later
Hearing Aid before 6 Spectacles before lazy eye develops

Movement disorders in the first 18 months of life

crucial to begin programming for problems in this area as quickly as possible because
Compensatory movements develop and prevent normal movement Exploration of the environment needed for the brain to develop all its functions Increasing size and weight make it harder for the child to move the part

EARLY IDENTIFICATION IS CRUCIAL

Impairment and Disability

Impairment (physical or intellectual) = lacking all or part of a limb or having a defective limb, organ or mechanism of the body.
Disability = the disadvantage or restriction of activity caused by society that excludes people with disabilities from the mainstream of social activities.
involves a social and human rights dimension

Often related to attitudes of family, community or society, or discriminatory laws, or architectural barriers.

Disabled people have long-term impairments that lead to

social and economic disadvantages denial of rights limited opportunities to play an equal part in the life of the community.

Terminology
Person with Disability (PWD), even better differently abled: not disabled A wheelchair user: not confined to a wheelchair Deaf: if you feel you need to refer to it you can say non speaking or better uses sign language but not deaf and dumb Slow learner or intellectual impairment: not mentally retarded

Disability versus Impairment

Group I
Lives independently Not disabled

Disability versus Impairment

Group 2
,

Some disability Needs some support

Disability versus Impairment

Group 3
Dependent on others Completely Disabled

Session Two

Red flags
Causes of Impairment

Red Flags
Causes of impairment

Health of Mother
Poor prenatal care Pre existing illness
Diabetes, drugs, STDs e.g Gonorrhoea *

During pregnancy
Drugs infections e.g. Measles* Chlamydia* Poor nutrition Certain medications taken by the mother (corticosteroids and phenytoin) Exposure to pesticides, chemicals and poisons
Deafness, Muscular Dystrophy, Downs Syndrome

Hereditable conditions Mother-baby blood incompatibility (Rh factor), Age

Over 40 during pregnancy.

During Birth
Premature Lack of oxygen* Low Birth weight Caesarian Section Difficult Birth
E.g Erbs Palsy

Low apgar scores

APGAR SCORES
Apgar scores Measurements of a baby's physical condition and mental alertness evaluated at one and five minutes after birth. The score is given for each of 5 signs, so the maximum Apgar score is 10 and indicates that the baby is in an optimum condition.

APGAR SCORES
Five systems are assessed:
PULSE RESPIRATORY EFFORT MUSCLE TONE COLOUR ON SUCTION

Each scores 2 for normal 1 for experiencing difficulties and 0 for absent

In infancy
Ear infection.
especially long lasting and repeated infections with pus

Exposure to frequent loud noise Meningitis Certain medications

streptomycin and related antibiotics

Poor Nutrition:
lacking in vitamin A found in milk, fruits and vegetables ,*
leads to Xerophthalmia or dry eyes a common cause of blindness

lack of iodine can cause Cretinism (mental retardation)

Injury* Brain damage/ tumours* Tapeworm in brain Trachoma* most common form of preventable blindness in the world It is

spread by touch or flies and is most common in poor crowded living conditions. Keeping the eyes clean and keeping flies away may prevent it.
* denotes a cause of visual impairment

Problems Developing in Childhood

Legge-Calve-Perthe Disease
Bow legs, knock knees

Muscular Dystrophy Seizures (fits, epilepsy) Low vision Deafness Psychiatric problems

Session Three Movement Problems

Cerebral Palsy
A movement disorder, but one that can include many other areas of impairment. A term for the condition caused by damage to the developing brain before during or after birth
All those in bold in the red flag section, but in about 30% of the cases there is no identifiable cause

Results
Varied depending on the severity of the brain damage and the part of the brain that is damaged

PROGNOSIS
One time event = long term problems treatment has to start as soon as child identified Treatment cannot cure the problem Treatment decreases the effects of the brain damage The baby cannot grow out of it , instead problems develop as the baby gets older

Cerebral Palsy continued

Can present with a wide range of problems Movement problems Cognitive impairment Hearing problems Vision problems Communication problems Sensory input problems

Cerebral Palsy continued

Mild to severe From able to function well in society to requiring total care. Some kind of communication is almost always possible, and this is of prime importance if it gives the person some ability to affect their own life One limb affected to all parts of the body affected

Alterations in muscle tone

Low Tone (Hypotonia)
Poor strength, trunk instability

High Tone (Spasticity)

Normal movement patterns interfered with by tight muscles e.g.Toe walking Joints at risk of contracture and subluxation

Altered Tone (Transient Dystonia)

Resists supported sitting May want to stand ++ Dislikes prone Can sometimes be seen in premature babies

Lack of movement control (Athetoid).

Sensory Input Impairment

An unseen disability that can have subtle or far reaching effects Use of the senses is the engine that creates our connection to the world. The brain can compensate but may do so with ways that seem abnormal to us

Sensory Input Impairment

An unseen disability that can have subtle or far reaching effects Involves all 5 senses as well as proprioceptive mechanism Use of the senses is the engine that creates our connection to the world. The brain can compensate but may do so with ways that seem abnormal to us

Results of Sensory Impairment

Poor motor planning Difficulty following instructions Tactile defensiveness Dislike of new things and change A need for routine and control Aggressive behaviors A need to reduce tension with repetitive movement such as flapping hands or rocking Seen with conditions such as cerebral palsy and autism spectrum disorders.

Movement
Begin as soon as possible Handle the child more not less than the normal Facilitate normal development patterns and encourage physical activites to
Decrease abnormal retention of reflex patterns of movement Prevent the development of compensatory movement patterns Strengthen weak muscles to reduce high tone in the paired muscles Prevent joints becoming fixed in abnormal position (contractures)

See a physiotherapist

Independence and ADL

Use all activities as opportunities to help the child gain independence When you do for a child something that they can do for themselves you are stealing their independence Any thing that the child can do and achieve on his own gives that child a chance to control something and this will increase the child's self esteem. See an Occupational Therapist

Importance of Play
Play is one of the key ways in which a baby or child learns and develops the skills he will need later in life. It is through play or the desire to play that the child normally achieves developmental milestones.

Sometimes a baby or child will need extra help to do this because of some developmental difficulties.
Family members help by giving extra stimulation from the adults and older children around him.

We learn to do something by doing it.

Milestones

Time Line Activity

Session Four: Communication Problems

Normal Speech and Language Development

Age Language development

Birth
0-3 months 4-6 months 7-12 months

Sounds
Differentiating cries - baby uses a different cry for different situations Vocal play - gurgling, babbling Speech like babbling including the use of consonants and vowels. First words "mama", "doggie" Use of two word questions - "No doggie?", "Where ball?" Two/three word utterances. Use of attributes - "Big", "Furry" Combination of four or more words in sentence form Use of long and detailed sentences. Use of "adult-like" grammar

1-2 years 2-3 years 3-4 years 4-5 years

Different parts of language

Phonology - a person's use of speech sounds, for example, /t/ in the sound /tea/. Syntax - the rules of grammar, for example knowing which order to place the subject, object and verb in a sentence, "[Subject] Daddy [verb] jumped over the [object] chair". Semantics - a person's ability to understand and create the meaning of language. Pragmatics - the ability to use language for the purpose of communication.

Cause for concern at 36 months

Unable to make mechanical toys work Unable to match objects to pictures Does not demonstrate make believe play with toys, dolls etc. Unable to sort objects by shape and color Cannot complete puzzles with three or four pieces Does not understands concept of two

Speech and Language Disorders

Articulation; Speech Sounds Language Delays/Disorders Social Communication Disorders Stammering Voice

Articulation disorders
Articulation disorders relate to an individuals ability to say particular sounds and/or string particular sounds together. Children are unable to produce particular sounds through the use of their lips, tongue, teeth, palate and even respiratory system, facial nerves and muscles. Children can be extremely hard to understand and may become frustrated at their inability to communicate

Language delays/disorders
Language delay is when a childs language is developing in the right sequence, but at a slower rate. Language disorder describes abnormal language development. Delayed speech or language development is the most common developmental problem

Social Communication Disorders

Marked impairments in the use of nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction Failure to develop peer relationships appropriate to developmental level A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people) Not actively participating in simple social play or games, preferring solitary activities

Stammering
Stammering or Stuttering is an involuntary repetition, prolongation or blockage of a word or part of a word that a person is trying to say. There are more than 45 million people in the world today who stammer.

Indications of a voice disorder

Hoarsenesscroaky or rough voice Weak voice Breathy voice Instable and/or monopitched voice You are whispering unintentionally You are using extra effort when speaking Coughing Throat may ache or feel dry Pain/discomfort when talking

What causes a voice disorder?

Organic voice disorders.. Relate to differences in the vocal tract (e.g. cleft palate) or to disease of specific structures of the vocal tract (e.g. Infections) Neurogenic voice disorders.. The muscles that control and/or innervate the muscles of respiration, phonation, resonance and articulation may be impaired from birth (e.g. cerebral palsy) or from an injury (e.g. stroke) Functional voice disorders.. Relate to the misuse of the vocal mechanism e.g. co-ordination of breathing and voice, abuse by yelling, coughing, smoking or throat clearing. Vocal misuse can be a cause of organic voice disorders like overall thickening of the vocal folds, nodules or vocal polyps

Hearing Impairment in children

Range from slight to profound Different causes Children may become deaf or loose hearing during childhood

Problems associated with deafness and a hearing impairment

Communication difficulties Learning difficulties

Other developmental problems

How can we identify a child who is hearing impaired?

Observe the child and talk to the caregivers: Does the child respond to sounds Is the child developing speech like other children Does the child respond to speech Does the child use a lot of gestures in her communication Has the child had any serious illnesses Were there any problems during pregnancy or birth

How can you help?

Hearing Impaired Child Have the child examined by a doctor, make sure infections are treated promptly. Refer for hearing assessment Assessment for hearing aid (ensure that it is worn and working) Teach the child to listen carefully Cut down on distracting noises Talk and sing to the child lots Speak clearly to the child but do not shout

How can you help?

Deaf Child Refer for hearing assessment Use many different methods of communication to the child. Make sure the child can see you clearly Face the child Speak clearly and loud, but do not shout or exaggerate mouth movements Communicate a lot, show him what you mean, with gestures, pictures or signs Encourage and praise a lot Practice games that use mouth muscles.

Session 5: Vision Problems

Vision Loss in Children

Difficulty with vision can be mild, moderate or severe. Some children are born blind and some become blind during early childhood or later. Not all children who are blind have eyes that look different. Their eyes may look clear and normal. The problem may be at the back of the eye or in the brain.

Signs that could mean a child has a vision problem

Eyes look dull, wrinkled or cloudy, or have sores or other obvious problems One or both pupils look gray or white By 3 months of age the childs eyes still do not follow an object or light that is moved in front of them The child does not reach out and pick up small objects Eyes cross or one eye turns in or out Child takes little interest in brightly coloured objects or pictures and books. Child has difficulty seeing after the sun sets (night blindness) Child cannot read letters on the blackboard or cannot read small print in books, or gets tired or often gets headaches when he reads.

Using Stimulation to Help Deal with Vision Loss

a completely blind child does not like to be left alone as this can feel like being abandoned. To reduce this when the child is lying in the cot the caregiver should sing or talk to the child as she moves around the home so give the baby lots of tactile and noise making toys of all varieties give lots of encouragement to engage in normal play activities. promote the use of hearing, smell, touch and taste to explore of the world around use touch and hugs as well as verbal indications to show praise and encouragement encourage walking, which may be slow. Falls and bumping into things helps in learning to balance and finding the way around so let the child do this in a safe environment. teach where things are and how to use the hands to feel. This will help in learning how to judge distances and how to in moving around the home without help. teach independence in daily activities such as bathing, toileting, eating and drinking use your hand over the child's hand until each task, such as dressing, has been learned do all the things you would do with a normal child e.g water play, manipulating with different textures, helping with household tasks (cooking, gardening, farming, laundry), visiting friends

Session 6: Learning and Socialisation Problems

By four years a child should..

Correctly name some colors Understand the concept of counting and may know a few numbers Follows three-part commands Recall parts of a story Understands the concepts of same and different Engage in fantasy play

Learning and Socialisation Problems

Developmental Disabilities
Learning Disabilities Socialisation Disorders

Developmental Disability
A developmental disability, or mental retardation, is a delay, or slowness, in a childs mental or developmental capacity. The child learns things more slowly than other children of the same age. They may be late at beginning to move, smile, show interest in things, use their hands, sit, walk, speak and understand others. Children with a developmental disability may take longer to learn certain skills, but with assistance and patience they can grow up to care for themselves.

Learning disability
A learning disability or difficulty means that a person has significant problems in understanding or using spoken or written language. These problems might be evident in the persons writing, maths, spelling or speaking and listening skills. Learning disabilities can affect the way the brain processes information.

Cause for concern at 36 months

Does no imitates adults and playmates Does not shows affection for familiar playmates Finds it difficult to take turns in games Does not understand concept of mine and his/hers

Signs of Learning Problems

Short term memory problems Reduced social interactions Low level language skills Easily distracted and short attention span Difficulty in copying from the board Difficulty in completing timed tasks Overly large handwriting Difficulty with spoken instructions Perceptual problems Illegible writing Poor hand-eye coordination

Cause for concern at 48 months

Shows little interest in new experiences Does not cooperates with other children Show little pretend play Requires lots of help to dress and undress

Socialisation Problems
Developmental Disorders Social Communication Disorder Emotional Disorders Abuse

Social Communication Disorders Autism

Language & Communication Social & Emotional
Difficulties with: Friendships Managing unstructured parts of the day Working co-operatively Difficulties processing and retaining information Difficulties understanding: Jokes and sarcasm Social use of language Literal interpretation Body language, facial expression and gesture

Flexibility of thought (imagination)

Difficulty with: Coping with changes in routines Empathy Generalisation

Reasons for delay in ASD

A child with an ASD may not see any reason to communicate with other people. Without a reason there is no point in communicating or no need to communicate. A child with an ASD may also remove themselves from situations that require communication, limiting their opportunities to communicate. Without opportunities there cannot be a development in communication.

Communication & Interaction

Most children with Autism will have difficulty interacting with others. It is important to remember that communication and interaction do not have to involve the use of language and speech.
Many children with an Autism are delayed in their use of language and shy away from using speech. Therefore, other methods of communication need to be established before speech and language will follow.

Session 8: Case Studies

Group Activity

Hearing Impairment: Referral

No medical referral required Audiology departments in Georgetown, Linden, Sudie and New Amsterdam Babies can be tested from the age of 4 months